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Nursing Health Assessment: A Best Practice Approach 3rd Edition
by Sharon Jensen MN RN (Author) latest Update.
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, Nursing Health Assessment A Best Practice Approach 3rd Edition Jensen
Test Bank
Chapter 1. Nurse’s Role In Health Assessment
1. After Completing An Initial Assessment Of A Patient, The Nurse Has Charted That His
RespirationsAre Eupneic And His Pulse Is 58 Beats Per Minute. These Types Of Data Would
Be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
Ans: A
Objective Data Are What The Health Professional Observes By Inspecting, Percussing, Palpating,
And Auscultating During The Physical Examination. Subjective Data Is What The Person Says
AboutHim Or Herself During History Taking. The Terms Reflective And Introspective Are Not
Used To Describe Data.
Dif: Cognitive Level: Understanding (Comprehension) Ref: Dm. 2
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
2. A Patient Tells The Nurse That He Is Very Nervous, Is Nauseated, And Feels Hot. These
Types OfData Would Be:
a. Objective.
b. Reflective.
c. Subjective.
d. Introspective.
Ans: C
Subjective Data Are What The Person Says About Him Or Herself During History Taking. Objective
Data Are What The Health Professional Observes By Inspecting, Percussing, Palpating, And
Auscultating During The Physical Examination. The Terms Reflective And Introspective Are
Not UsedTo Describe Data.
Dif: Cognitive Level: Understanding (Comprehension) Ref: Dm. 2
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
3. The Patients Record, Laboratory Studies, Objective Data, And Subjective Data Combine
To FormThe:
a. Data Base.
b. Admitting Data.
c. Financial Statement.
d. Discharge
Summary.Ans: A
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,Together With The Patients Record And Laboratory Studies, The Objective And Subjective
Data FormThe Data Base. The Other Items Are Not Part Of The Patients Record, Laboratory
Studies, Or Data.
Dif: Cognitive Level: Remembering (Knowledge) Ref: Dm. 2
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
4. When Listening To A Patients Breath Sounds, The Nurse Is Unsure Of A Sound That Is
Heard. TheNurses Next Action Should Be To:
a. Immediately Notify The Patients Physician.
b. Document The Sound Exactly As It Was Heard.
c. Validate The Data By Asking A Coworker To Listen To The Breath Sounds.
d. Assess Again In 20 Minutes To Note Whether The Sound Is Still
Present.Ans: C
When Unsure Of A Sound Heard While Listening To A Patients Breath Sounds, The Nurse Validates The
Data To Ensure Accuracy. If The Nurse Has Less Experience In An Area, Then He Or She
Asks An ExpertTo Listen.
Dif: Cognitive Level: Analyzing (Analysis) Ref: Dm. 2
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
5. The Nurse Is Conducting A Class For New Graduate Nurses. During The Teaching
Session, The Nurse Should Keep In Mind That Novice Nurses, Without A Background Of
Skills And ExperienceFrom Which To Draw, Are More Likely To Make Their Decisions
Using:
a. Intuition.
b. A Set Of Rules.
c. Articles In Journals.
d. Advice From
Supervisors.Ans: B
Novice Nurses Operate From A Set Of Defined, Structured Rules. The Expert Practitioner Uses
Intuitive Links.
Dif: Cognitive Level: Understanding (Comprehension) Ref: Dm. 3
Msc: Client Needs: General
6. Expert Nurses Learn To Attend To A Pattern Of Assessment Data And Act Without
ConsciouslyLabeling It. These Responses Are Referred To As:
a. Intuition.
b. The Nursing Process.
c. Clinical Knowledge.
d. Diagnostic
Reasoning.Ans: A
Intuition Is Characterized By Pattern Recognitionexpert Nurses Learn To Attend To A Pattern Of
Assessment Data And Act Without Consciously Labeling It. The Other Options Are Not
Correct.Dif: Cognitive Level: Understanding (Comprehension) Ref: Dm. 4
Msc: Client Needs: General
7. The Nurse Is Reviewing Information About Evidence-Based Practice (Ebp). Which
StatementBest Reflects Ebp?
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, a. Ebp Relies On Tradition For Support Of Best Practices.
b. Ebp Is Simply The Use Of Best Practice Techniques For The Treatment Of Patients.
c. Ebp Emphasizes The Use Of Best Evidence With The Clinicians Experience.
d. The Patients Own Preferences Are Not Important With
Ebp.Ans: C
Ebp Is A Systematic Approach To Practice That Emphasizes The Use Of Best Evidence In Combination
With The Clinicians Experience, As Well As Patient Preferences And Values, When Making
DecisionsAbout Care And Treatment. Ebp Is More Than Simply Using The Best Practice
Techniques To Treat Patients, And Questioning Tradition Is Important When No Compelling
And Supportive Research Evidence Exists.
Dif: Cognitive Level: Applying (Application) Ref: Dm. 5
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
8. The Nurse Is Conducting A Class On Priority Setting For A Group Of New Graduate
Nurses. WhichIs An Example Of A First-Level Priority Problem?
a. Patient With Postoperative Pain
b. Newly Diagnosed Patient With Diabetes Who Needs Diabetic Teaching
c. Individual With A Small Laceration On The Sole Of The Foot
d. Individual With Shortness Of Breath And Respiratory
DistressAns: D
First-Level Priority Problems Are Those That Are Emergent, Life Threatening, And Immediate (E.G.,
Establishing An Airway, Supporting Breathing, Maintaining Circulation, Monitoring Abnormal
VitalSigns) (See Table 1-1).
Dif: Cognitive Level: Understanding (Comprehension) Ref: Dm. 4
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
9. When Considering Priority Setting Of Problems, The Nurse Keeps In Mind That
Second-LevelPriority Problems Include Which Of These Aspects?
a. Low Self-Esteem
b. Lack Of Knowledge
c. Abnormal Laboratory Values
d. Severely Abnormal Vital
SignsAns: C
Second-Level Priority Problems Are Those That Require Prompt Intervention To Forestall Further
Deterioration (E.G., Mental Status Change, Acute Pain, Abnormal Laboratory Values, Risks
To SafetyOr Security) (See Table 1-1).
Dif: Cognitive Level: Understanding (Comprehension) Ref: Dm. 4
Msc: Client Needs: Safe And Effective Care Environment: Management Of Care
10. Which Critical Thinking Skill Helps The Nurse See Relationships Among The Data?
a. Validation
b. Clustering Related Cues
c. Identifying Gaps In Data
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